NEW YORK SPINE INSTITUTE Medical solutions lor spine disorders
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1 NEW YORK SPINE INSTITUTE Medical solutions lor spine disorders NO FAULT HISTORY CHECK OFF IF POSITIVE: PATIENT NAME: DATE OF THE ACCIDENT: j j _ CHIEF COMPLAINT _ WHERE IS PAIN WORST? )NECK )BACK )OTHER, 1. YOU WERE THE: ( ) DRIVER ( ) PEDESTRIAN ) PASSENGER SITTING IN THE: (R) REAR or (L) REAR or (R) FRONT 2. ) WEARING A SEAT BELT ) LOST CONSCIOUSNESS 3. ) THE CAR WAS STOPPED ) THE CAR WAS MOVING 4. TYPE OF VEHICLE YOU WERE IN: 5. TYPE OF VEHICLE YOU WERE STRUCK BY: 6. ANY PRIOR MOTOR VEHICLE ACCIDENTS? 7. PRIOR HISTORY OF NECK OR BACK PAIN? 8. TREATMENTS YOU HAVE RECEIVED TO DATE: )CAR )TRUCK )VAN )BUS ) MOTORCYCLE ) TAXI )CAR )TRUCK )VAN )BUS ) MOTORCYCLE ) TAXI ) PHYSICAL THERAPY ) CHIROPRACTIC CARE )ACCUPUNCTURE ) EPIDURAL INJECTIONS ) TRIGGER POINT INJECTION ) DIAGNOSTIC IMAGING 9. ARE YOU CURRENTLY WORKING?
2 10. ARE YOU DOING ) BETTER )WORSE )SAME ANY OTHER MEDICAL PROBLEMS? OCCUPATION & EMPWYER NAME: SOCIAL HISTORY: SMOKE? ) YES, HOW MUCH? DRINK? ) YES, HOW MUCH? LIST ANY OPERATIONS AND/OR HOSPITALIZATIONS (WITH DATES) ANY RADIOLOGY TESTING? ANY KNOWN ALLERGIES? PAIN DRAWING & SCALE REVIEW Patient Name (PRINT): Signature: Date:
3 NEW YORK MOTOR VECHILE NO-FAULT INSURANCE LAW ASSIGNMENT OF BENEFITS FORM (FOR ACCIDENTS OCCURING IN AND AFTER 3/1/02) New York Spine Institute I, ("Assignor'') hereby assign Dr. Alexandre B. de Moura, Dr. Adam Landskowsky, Dr. Orlando Ortiz, Dr. Benjamin Hirsch, Dr. Peter Passias, Dr. Angel Macagno, Michael Friar, OPT, Dr. David Khanan ("Assignees") (Print Hospital or Health Care Provider Name) All rights privileges and remedies to payment for health care services provided by assignee to which I am entitled under Article 51 (No-Fault Statute) of the Insurance Law. The Assignee hereby certifies that they have not received any payment from or on behalf of the Assignor and shall not purse payment directly from the Assignor for services provided by said Assignee for injuries sustained due to the motor vehicle which occurred on notwithstanding any other agreement to the contrary. (Print accident date) The agreement may be revoked by the assignee when benefits are not payable based upon the assignor's lack of coverage and/or violation of a policy condition due to the actions or conducts of the assignor. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM FOR ANY COMMERICAL OR PERSONAL INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, AND ANY PERSON WHO, IN CONNECTION WITH SUCH APPLICATION OR CLAIM, KNOWINGLY MAKES OR KNOWINGLY ASSISTS, ABETS, SOLICITS OR CONSPIRES WITH ANOTHER TO MAKE FALSE REPORT OF THE THEFT, DESTRUCTION, DAMAGE OR CONVERSION OF ANY MOTOR VEHICLES OR AN INSURANCE COMPANY, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE VALUE OF THE SUBJECT MOTOR VEHICLE OR STATED CLAIM FOR EACH VIOLATION. (Print name of Patient) (Signature of Patient) (Address of Patient) (Date of Signature) (Address of Patient) NEW YORK SPINE INSTITUTE Dr. Alexandre B. de Moura, Dr. Peter Passias, Dr. Angel Macagno, Dr. Orlando Ortiz, Dr. Benjamin Hirsch, Michael Friar, DPT, Dr. Adam Landskowsky, Dr. David Khanan (Print name of Provider) 761 MERRICK AVENUE (Signature of Provider) (Date of Signature) WESTBURY, NEW YORK (Address of Provider) NYS FORM NF-AOB (Rev 1/2004)
4 NEW YORK SPINE INSTITUTE Medical solutions lor spine disonlers Alexandre de Moura, M.D., PC, DBA, New York Spine Institute 761 Merrick Ave. Westbury, New York ASSIGNMENT OF RECOVERY PROCEEDS AND AUTHORIZATION TO ALEXANDRE DE MOURA, M.D., PC, DBA, NEW YORK SPINE INSTITUTE PATIENT: ADDRESS: ATTORNEY: I,, the undersigned, do hereby assign to Alexandre de Moura, M.D., PC, DBA, New York Spine Institute, any sums due and payable, received by me or on my behalf, from any source for any and all medical treatment and or fees for services rendered to me and/or my attorney. I authorize and direct my attorney to deduct and immediately pay Alexandre de Moura, M.D., PC, DBA New York Spine Institute, and such fees as may be due and payable for the assigned monies that may come into my hands or my attorney's hands in any recovery resulting from any claims or lawsuit. I further direct my attorney to contact Alexandre de Moura, M.D., PC, DBA, New York Spine Institute, to determine the exact amount owed before any money is paid to me from any recovery resulting from any claim or lawsuit. I further direct my attorney to advise Alexandre de Moura, M.D., PC, DBA, New York Spine Institute, upon request, of the status of my lawsuits and/ or any claims which may result in a monetary recovery from which the fees due and payable to Alexandre de Moura, M.D., PC, DBA, New York Spine Institute, may be satisfied. If my attorney is replaced by another attorney, I direct that the outgoing attorney not forward my file until written acknowledgement from my new attorney is signed and forwarded to the undersigned acknowledging the terms and conditions set forth in this assignment.
5 Alexandre de Moura, M.D., PC, DBA, New York Spine Institute, agrees to provide reasonable cooperation in connection with securing payment for all insurance c1aims to the extent required by law. In the event of any breach ofthis assignment by the patient and/or the patient's attorney, it is understood that the patient shall remain responsible for all legal fees required to either obtain insurance information and/or collect any monies owed to Alexandre de Moura, M.D, PC, DBA, New York Spine Institute, plus the expense oflitigation and/or arbitration. It is understood that this agreement, in no manner whatsoever, makes the payment of the fees due and payable to Alexandre de Moura, M.D., PC, DBA, New York Spine Institute contingent upon securing a recovery in any lawsuit or in any insurance claim that I may have. I understand that I remain personally responsible for all fees for medical treatment, as well as for services rendered on my behalf to my attorney and that I am personally liable for payment of the same; Further, I acknowledge that this assignment does not, in any fashion, preclude or otherwise prevent Alexandre de Moura, M.D., PC, DBA, New York Spine Institute, from demanding payment at any time after such services, as embraced within this assignment, are rendered. (Patient or Legal Guardian Signature) witness THE TERMS AND CONDmONS OF THE FOREGOING ASSIGNMENT ARE UNDERSTOOD AND AGREED TO, BY: ATTORNEY: ADDRESS: ATTORNEYS SIGNATURE: DATED:
ALEXANDRE B. DEMOURA, MD PC PATIENT DEMOGRAPHIC NAME: DATE: / / ADDRESS: CITY: STATE: ZIP: PHONE: (HOME) (CELL) HEIGHT S.S. # SEX: M / F D.O.B:.
ALEXANDRE B. DEMOURA, MD PC PATIENT DEMOGRAPHIC NAME: DATE: / / ADDRESS: CITY: STATE: ZIP: PHONE: (HOME) (CELL) HEIGHT WEIGHT S.S. # SEX: M / F D.O.B:. AGE: RACE: ETHNICITY: PERFERRED LANGUAGE: MARTIAL
ITHACAMED NO FAULT CLAIM INFORMATION
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